Roger Wilson, Emma Kinloch, Lydia E Makaroff, Anna Bailey-Bearfield, Richard Stephens, Janette Rawlinson, Kathy Oliver
First published in www.thelancet.com/oncology Vol 24 in May 2023
The UK Secretary of State for Health and Social Care, Stephen Barclay, has set out plans for an alternative approach to cancer service provision based on a major conditions strategy.1 The six areas for inclusion in the strategy are cancer, cardiovascular disease, respiratory disease, dementia, mental health, and musculo- skeletal disorders. All these areas are priorities for a national health strategy but is lumping them all together an effective route to success in treating them? As patients and patient advocates, we do not consider that this approach is wise, either for people with these diseases or for the National Health Service (NHS).
A holistic approach to patient care can be helpful, and there are many scenarios when “integrated, whole-person care”, as promised by this new strategy [1], is appropriate and beneficial; however, understanding comorbidities is vital to treatment outcomes and experiences and a key part of clinical decision making for individual patients, and is very different to merging diseases in a national strategy that will dilute attention to specific areas.
The most recent cancer plan for England was published in July 2015.[2] It set out clear and rational ambitions for improving outcomes for people with cancer. Two significant challenges put the plan at risk. First, there were growing workforce shortages and second, a promised “radical upgrade in prevention”[2] failed, partly because local public health budgets were cut, including smoking prevention budgets. The 2015 strategy partly reversed the 2012 dismantling of the National Cancer Team by Andrew Lansley, the former UK Secretary of State for Health, and now there is renewed national leadership for cancer services with responsibility for the cancer strategy and local cancer alliances, made up of doctors and NHS managers once again providing local leadership.
Capacity in NHS cancer services has become an even more significant challenge. Demand continues to increase, diagnostic technology provision is poor, increasingly demoralised NHS staff are working harder than ever to keep up, waiting times continue to increase, and treatment targets are being missed;[3] treatment targets that were rationally defined, albeit 20 years ago, and have been explicitly supported by the UK Government.
These targets appear simple, but they conceal complex processes that require collaborative work between clinical and scientific disciplines. These processes focus on delivering effective cancer care from the consideration of the symptoms and clinical situation of the patient, throughout its treatment (assuming treatment options are available), to after-care, and follow-up. Delays in care can lead to people missing out on effective treatment and result in avoidable deaths from cancer.[4] Treating cancers involves a team with specific training, experience, and remit. Planning for all this requires a specific and targeted approach that should be explicitly differentiated from other major diseases.
Cancer complexity is increasing as genetic sequencing blurs traditional tumour definitions and opens the way for innovation and stratified or precision medicine. The positive effect of innovative technology, genetically defined drugs, artificial intelligence, and surgical robotics has been discussed in the media; however, these technologies are only part of the solution and currently cure few people. Such advances will have little effect on most patients who are diagnosed with cancer in the next 10 years, even if some headline-grabbing success stories occur.
Despite continuing political commitments to cancer, we see that the prospects for patients with cancer in England have deteriorated and are worsening. The burden is greatest in disadvantaged areas.[5] Although there is much rhetoric about so-called levelling up, we have seen the Government’s commitment to tackling health disparities diluted by scrapping the planned publication of a White Paper on health disparities in January 2023. Additionally, although some may believe that these deteriorating prospects are due to the lasting effects of the COVID-19 pandemic, the decline in addressing cancer performance targets dates back at least a decade.
As experienced advocates for people with cancer, the more we look at the introduction to the major conditions strategy, the more we are concerned that it will deliver uniform inadequacy for most people in all six target groups. With such a considerable remit, a paucity of detail in each area will be inevitable, giving room for the degrading of current commitments. Existing targets could be replaced with new ones shaped to fit the practicalities of what is planned. This degradation will most probably affect the timing and quality of care for those with rarer conditions, which includes many cancers. This could be disastrous. There will inevitably be a search for more headline-grabbing success stories to justify the process, and the bigger picture will be hidden from view.
We are also concerned that developing a major conditions strategy will take time, not least to reconcile the inevitable clashes and conflicts from the needs of patients in different disease groups. The work for the new cancer plan was near completion, and the evidence to underpin it was well established. Pre-empting the cancer plan as proposed will enable the UK Government to avoid investment in cancer to fund other demands.
We recall the situation under John Major’s Government, analysed by Professor Sir Kenneth Calman (Chief Medical Officer for England), Dame Deirdre Hine (Chief Medical Officer for Wales), and a team of experts in 1995.6 The Calman–Hine report laid the foundations for improving cancer services up to 2010. It advocated a change from a generalist model of cancer care to a fully specialist service. Patient groups noted the accelerating change happening from 2000 onwards, supported by sustainable mechanisms for debating and implementing well-designed policies, an enthused and growing oncology profession, and strengthening of our patient voice. Despite these improvements, treatment and survival failed to keep up with international benchmarks.[7]
Those making decisions about the direction of cancer care must learn from what happened in England in 1995–2010 and in other countries during the last 20 years as national cancer plans were initiated. A health service that listens to what its patients say and delivers quick and accurate diagnoses, prompt expert treatment, effective follow-up, and innovative treatments for advanced disease will deliver continuous improvements in survival, quality of life, and enhanced quality of care. This effectiveness feeds back into prevention activity, whether focused on stopping smoking or increased uptake of screening; it is these outcomes, above all others that patients call for and need. Anything that reduces or removes, the ability of healthcare services to deliver these outcomes is to be decried.
What is happening worldwide shows that national cancer plans make a difference. They foster specialist cancer networks that develop specific skills collaboratively and can focus on complex clinical and non-clinical needs, not just medical needs. These networks meet the expectations of patients and their families. Such structures anchor actions to prevent cancers. The Beating Cancer Plan published by the European Commission8 shows how all-embracing and essential a clear and dedicated plan for cancer can be. It offers a specific challenge to EU member nations, positioning cancer research and clinical innovation at the heart of improving cancer care. The plan has an important focus on survivorship and identifies flagship actions that include investing in earlier diagnosis, specialist centres, and children’s care, as well as reducing health inequalities.
The Lancet Oncology European Groundshot Commission[9] for cancer research offers specific challenges that a national cancer plan for England should address. Cancer research also has a role in the UK Government’s broader life sciences challenge. It is not immediately obvious how removing the specificity of these activities will “align to the government’s ambitious life sciences missions”.[1]
England needs a fresh, dynamic national cancer plan reflecting the complexity of the disease. As patients, we must engage with the development of the major conditions strategy and look for a clear, focused cancer plan to evolve from it. Like other nations, England must provide efficient, effective, and well-resourced cancer services with integrated research that listens to patients. We are concerned that combining strategies for cancer with those for other diseases risks this objective for all. The needs of people with cancer will not be addressed by forcing cancer into a generalist strategy—the lessons of history have shown us this.
Roger Wilson, Emma Kinloch, Lydia E Makaroff, Anna Bailey-Bearfield, Richard Stephens, Janette Rawlinson, Kathy Oliver
Patient Advocate, Shropshire, UK (RW); Salivary Gland Cancer UK, London, UK (EK); Fight Bladder Cancer, Oxfordshire, UK (LEM); Pancreatic Cancer UK, London, UK (AB-B); Patient Advocate, Stevenage, UK (RS); Patient Advocate, West Midlands, UK (JR); International Brain Tumour Alliance, Surrey, UK (KO)
References:
1 Barclay S. Major conditions and diseases announcement. Jan 24, 2023. Hansard, Commons. https://hansard.parliament.uk/Commons/2023-01-24/ debates/23012433000010/MajorConditionsAndDiseases (accessed
Feb 24, 2023).
2 Independent Cancer Taskforce. Achieving world-class cancer outcomes: a strategy for England 2015–2020. 2015. https://www.cancerresearchuk. org/sites/default/files/achieving_world-class_cancer_outcomes_-_a_ strategy_for_england_2015-2020.pdf (accessed Feb 24, 2023).
3 Price P, Sullivan R, Ahmed A, Wishart GC. UK cancer care: a watershed moment and the need for urgent intervention. Lancet Oncol 2023; 24: 133–38.
4 Hanna TP, King WD, Thibodeau S, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ 2020; 371: m4087.
5 National Health Service. Cancer registration statistics, England 2019. Oct 21, 2021. https://digital.nhs.uk/data-and-information/publications/ statistical/cancer-registration-statistics/england-2019/there-are-higher- rates-of-cancer-in-the-most-deprived-areas (accessed March 13, 2023).
6 Calman K, Hine D. A policy framework for commissioning cancer services: a report by the expert advisory group on cancer to the Chief Medical Officers of England and Wales. April, 1995. http://www.surginet.org.uk/ misc/interview/downloads/doh/cancerfr_CALMAN_HINE.pdf (accessed March 9, 2023).
7 WHO. International Agency for Research on Cancer: ICBP SURVMARK-2. 2019. https://gco.iarc.fr/survival/survmark/ (accessed March 13, 2023).
8 European Commission. Europe’s Beating Cancer Plan. 2021. https://health. ec.europa.eu/system/files/2022-02/eu_cancer-plan_en_0.pdf (accessed March 13, 2023).
9 Lawler M, Davies L, Oberst S, et al. European Groundshot—addressing Europe’s cancer research challenges: a Lancet Oncology Commission. Lancet Oncol 2023; 24: e11–56.